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    <form class="center" data-form-token="Jk0qyS" data-validate-url="/f/Jk0qyS/validate_fields" id="new_entry" action="/f/Jk0qyS" accept-charset="UTF-8" method="post"><input type="hidden" name="utf8" value="&#x2713;" /><input type="hidden" name="authenticity_token" value="WgekRaqX31XVqLQwqEvPY7xsConeL/yPEtrf48sDiwj6uMouN8UYuaqKLfR8qrEEK4KcfPyNqxN2Dpk0rxIIqQ==" />
        <div class="banner">
            <div class="banner-img">
                <img data-img-url="https://dn-jsjpub.qbox.me/hi/5538b5f841505056f86e00001429779960.jpg" data-img-prefix="hi" class="header-image need-adapt-retina" src="" />
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        <div class="form-header container-fluid">
            <div class="row">
                <h1 class="form-title col-md-12">
                    好头发脱发问卷调查
                </h1>
                <div class="form-description col-md-12"><p>请认真填写以下内容，以便头发专家给出准确结果，谢谢。</p></div>
            </div>
        </div>
        <div class="form-content container-fluid">
            <div class="row">

                <div class="fields clearfix">
                    <div class="field field-drop-down col-sm-12 required" data-api-code="field_1" data-type="DropDown" data-label="您的年龄" data-validations="[&quot;Presence&quot;]">


                        <div class="form-group" >
                            <div class="field-label-container" onclick="">
                                <label class="field-label" for="entry_field_1">
                                    您的年龄
                                </label>
                            </div>
                            <div class="field-content">

                                <select name="entry[field_1]" id="entry_field_1" class="needsclick" data-has-error="false"><option value="">请选择</option><option value="canL">14-20</option>
                                    <option value="YP70">20~30</option>
                                    <option value="Ojcq">30-40</option>
                                    <option value="lue4">40-50</option>
                                    <option value="tPud">50岁以上</option></select>



                            </div>
                        </div>


                    </div>              <div class="field field-text-field col-sm-12 required" data-api-code="field_20" data-type="TextField" data-label="所在地（省）" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_20">
                                所在地（省）
                            </label>
                        </div>
                        <div class="field-content">

                            <input type="text" name="entry[field_20]" id="entry_field_20" />

                        </div>
                    </div>


                </div>              <div class="field field-drop-down col-sm-12 required" data-api-code="field_2" data-type="DropDown" data-label="婚育情况" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_2">
                                婚育情况
                            </label>
                        </div>
                        <div class="field-content">

                            <select name="entry[field_2]" id="entry_field_2" class="needsclick" data-has-error="false"><option value="">请选择</option><option value="yxez">单身</option>
                                <option value="685h">已婚未育</option>
                                <option value="ca3O">近期准备造人</option>
                                <option value="TSUk">娃已会打酱油</option></select>



                        </div>
                    </div>


                </div>              <div class="field field-radio-button col-sm-12 required" data-api-code="field_3" data-type="RadioButton" data-label="您的职业" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_3">
                                您的职业
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="7OQ7" name="entry[field_3]" />
                                    <div class="choice-description">
                                        学生党
                                    </div>
                                </label>
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="OJce" name="entry[field_3]" />
                                    <div class="choice-description">
                                        白班族
                                    </div>
                                </label>
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="NdD5" name="entry[field_3]" />
                                    <div class="choice-description">
                                        夜班族
                                    </div>
                                </label>
                                <div class="other-choice-area inline">
                                    <label onclick="" class="radio inline ">
                                        <input class="other_choice" data-field-key="field_3" type="radio" value="Ku5M" name="entry[field_3]" />
                                        <div class="choice-description">
                                            其他
                                        </div>
                                    </label>
                                    <span class="other-choice-input-container"><input class="other-choice-input gd-input-medium gd-input-thin fixed-width-control" data-field-key="field_3" type="text" value="" name="entry[field_3_other]" id="entry_field_3_other" /></span>
                                </div>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_16" data-type="CheckBox" data-label="您目前的生活状态" data-validations="[&quot;Presence&quot;,&quot;Length&quot;]" data-minimum-length="1" data-maximum-length="5" data-length-hint="选1-5项">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_16">
                                您目前的生活状态<span>（选1-5项）</span>
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="s5aC" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        精神压力大
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="Bl08" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        脑力劳动
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="ThZS" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        经常带帽子
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="Eper" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        重体力劳动
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="WHWl" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        长时间使用电子设备
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="ZlmF" name="entry[field_16][]" />
                                    <div class="choice-description">
                                        吸烟
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_4" data-type="CheckBox" data-label="您脱发多久了" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_4">
                                您脱发多久了
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="TR3v" name="entry[field_4][]" />
                                    <div class="choice-description">
                                        不到1年
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="KDL4" name="entry[field_4][]" />
                                    <div class="choice-description">
                                        1年-2年
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="VHyE" name="entry[field_4][]" />
                                    <div class="choice-description">
                                        2年-3年
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="ZYXZ" name="entry[field_4][]" />
                                    <div class="choice-description">
                                        3年以上
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_10" data-type="CheckBox" data-label="是否治疗过，每年花费是多少？" data-validations="[&quot;Presence&quot;,&quot;Length&quot;]" data-minimum-length="1" data-maximum-length="1" data-length-hint="选1项">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_10">
                                是否治疗过，每年花费是多少？<span>（选1项）</span>
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="n4BU" name="entry[field_10][]" />
                                    <div class="choice-description">
                                        没有治疗过
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="FvFq" name="entry[field_10][]" />
                                    <div class="choice-description">
                                        每年花费2000-5000元
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="qTVb" name="entry[field_10][]" />
                                    <div class="choice-description">
                                        每年花费5000元以上
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="k1s6" name="entry[field_10][]" />
                                    <div class="choice-description">
                                        不知道该怎么办
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_13" data-type="CheckBox" data-label="头皮情况" data-validations="[&quot;Presence&quot;,&quot;Length&quot;]" data-minimum-length="1" data-maximum-length="4" data-length-hint="选1-4项">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_13">
                                头皮情况<span>（选1-4项）</span>
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="L1rs" name="entry[field_13][]" />
                                    <div class="choice-description">
                                        正常
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="cZj0" name="entry[field_13][]" />
                                    <div class="choice-description">
                                        出油多
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="ZU2L" name="entry[field_13][]" />
                                    <div class="choice-description">
                                        头屑多
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="ULAJ" name="entry[field_13][]" />
                                    <div class="choice-description">
                                        头皮痒
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="4145" name="entry[field_13][]" />
                                    <div class="choice-description">
                                        毛囊炎
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_7" data-type="CheckBox" data-label="睡眠情况" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_7">
                                睡眠情况
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="oMxB" name="entry[field_7][]" />
                                    <div class="choice-description">
                                        睡得很好
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="mcvN" name="entry[field_7][]" />
                                    <div class="choice-description">
                                        常熬夜
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="5b2u" name="entry[field_7][]" />
                                    <div class="choice-description">
                                        睡眠质量差
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-check-box col-sm-12 required" data-api-code="field_14" data-type="CheckBox" data-label="饮食习惯" data-validations="[&quot;Presence&quot;,&quot;Length&quot;]" data-minimum-length="1" data-maximum-length="4" data-length-hint="选1-4项">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_14">
                                饮食习惯<span>（选1-4项）</span>
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="012Y" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        素食主义者
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="eVrk" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        无肉不欢
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="4m1C" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        偏油腻、爱吃垃圾食品
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="AZnm" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        爱吃甜食
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="00Cx" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        节食减肥
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="g4xr" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        酗酒
                                    </div>
                                </label>
                                <label onclick="" class="checkbox inline">
                                    <input type="checkbox" value="Lads" name="entry[field_14][]" />
                                    <div class="choice-description">
                                        正常
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-radio-button col-sm-12 required" data-api-code="field_15" data-type="RadioButton" data-label="每天掉发数量" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_15">
                                每天掉发数量
                            </label>
                        </div>
                        <div class="field-content">

                            <div class="choices">
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="fzyY" name="entry[field_15]" />
                                    <div class="choice-description">
                                        不到10根
                                    </div>
                                </label>
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="0lUv" name="entry[field_15]" />
                                    <div class="choice-description">
                                        不到80根
                                    </div>
                                </label>
                                <label onclick="" class="radio inline">
                                    <input type="radio" value="P3nT" name="entry[field_15]" />
                                    <div class="choice-description">
                                        80根以上
                                    </div>
                                </label>
                            </div>


                        </div>
                    </div>


                </div>              <div class="field field-image-radio-button col-sm-12 required" data-api-code="field_9" data-type="ImageRadioButton" data-label="您现在的头发状态" data-validations="[&quot;Presence&quot;]">


                    <div class="form-group" >
                        <div class="field-label-container" onclick="">
                            <label class="field-label" for="entry_field_9">
                                您现在的头发状态
                            </label>
                        </div>
                        <div class="field-content">

                            <div class='choices image-choices'>
                                <label onclick="" class="radio">
                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="男性脱发2级" href="https://dn-jsjpub.qbox.me/ic/20160323175010_c94ed0@icxlarge">
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                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="男性脱发3级" href="https://dn-jsjpub.qbox.me/ic/20160323175144_072eda@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175144_072eda@iclarge'>加载中...</div>
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                                    </div>

                                    <div class="text-wrapper">
                                        <input type="radio" value="BBfR" name="entry[field_9]" />
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                                            男性脱发3级
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                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="男性脱发4级" href="https://dn-jsjpub.qbox.me/ic/20160323175144_6cc894@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175144_6cc894@iclarge'>加载中...</div>
                                        </a>
                                    </div>

                                    <div class="text-wrapper">
                                        <input type="radio" value="Jc8T" name="entry[field_9]" />
                                        <div class="choice-description">
                                            男性脱发4级
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                                <label onclick="" class="radio">
                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="男性脱发5级" href="https://dn-jsjpub.qbox.me/ic/20160323175144_65a9c7@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175144_65a9c7@iclarge'>加载中...</div>
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                                        <input type="radio" value="ppr8" name="entry[field_9]" />
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                                            男性脱发5级
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                                    <div class="quota"></div>
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                                <label onclick="" class="radio">
                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="中分处可看到明显头皮" href="https://dn-jsjpub.qbox.me/ic/20160323175426_862ac4@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175426_862ac4@iclarge'>加载中...</div>
                                        </a>
                                    </div>

                                    <div class="text-wrapper">
                                        <input type="radio" value="AS5w" name="entry[field_9]" />
                                        <div class="choice-description">
                                            中分处可看到明显头皮
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                                    <div class="quota"></div>
                                </label>
                                <label onclick="" class="radio">
                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="中分处明显看到头皮，稀疏范围扩大。" href="https://dn-jsjpub.qbox.me/ic/20160323175640_a22013@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175640_a22013@iclarge'>加载中...</div>
                                        </a>
                                    </div>

                                    <div class="text-wrapper">
                                        <input type="radio" value="QgBN" name="entry[field_9]" />
                                        <div class="choice-description">
                                            中分处明显看到头皮，稀疏范围扩大。
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                                    </div>
                                    <div class="quota"></div>
                                </label>
                                <label onclick="" class="radio">
                                    <div class="image-center">
                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="中分处明显看到头皮，稀疏范围约2/3头顶。" href="https://dn-jsjpub.qbox.me/ic/20160323175640_1d2cb6@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175640_1d2cb6@iclarge'>加载中...</div>
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                                    <div class="text-wrapper">
                                        <input type="radio" value="WzBI" name="entry[field_9]" />
                                        <div class="choice-description">
                                            中分处明显看到头皮，稀疏范围约2/3头顶。
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                                    <div class="quota"></div>
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                                <label onclick="" class="radio">
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                                        <a class="lightbox-image-link" rel="lightbox[field_9]" title="头顶严重脱发，头发非常稀疏。" href="https://dn-jsjpub.qbox.me/ic/20160323175640_918f7c@icxlarge">
                                            <div class="image-loading" data-url='https://dn-jsjpub.qbox.me/ic/20160323175640_918f7c@iclarge'>加载中...</div>
                                        </a>
                                    </div>

                                    <div class="text-wrapper">
                                        <input type="radio" value="u8X9" name="entry[field_9]" />
                                        <div class="choice-description">
                                            头顶严重脱发，头发非常稀疏。
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                                    </div>
                                    <div class="quota"></div>
                                </label>
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                </div>              <div class="field field-radio-button col-sm-12 required" data-api-code="field_17" data-type="RadioButton" data-label="是否有脱发家族遗传" data-validations="[&quot;Presence&quot;]">


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                                        有
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                </div>              <div class="field field-text-field col-sm-12" data-api-code="field_11" data-type="TextField" data-label="需要医生指导请填写微信号（有机会获得免费试用洗发水）" data-validations="[]">


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